Effect of short‐term dynamic psychotherapy on sexual function and marital satisfaction in women with depression: Clinical trial study

Abstract Background and Aims This study aimed to look at the influence of short‐term dynamic psychotherapy on sexual function and marital satisfaction in women with depression. Methods Through a clinical trial study using a pretest–posttest design and a control group, this study enlisted the participation of 60 women diagnosed with depression. The patients were interviewed before being randomly assigned to experimental or control groups. Data were obtained through the Beck Depression Inventory, the Enrique Marital Satisfaction Questionnaire, and the Female Sexual Function Questionnaire. The experimental group received intense short‐term dynamic psychotherapy intervention, while the control group was on a 2‐month waiting list. The SPSS 24 program utilized an analysis of variance to analyze the data. Results The pre‐ and posttest study results revealed a significant difference in marital satisfaction, sexual function, and depression between the experimental and control groups (p < 0.01). Conclusion During the posttest phase, a short‐term intensive dynamic psychotherapy intervention helped the experimental group feel better about their marriage and improve their sexual function. It also helped them feel less depressed.

People who engage in acrimonious relationships with one another are often overpowered by unpleasant sentiments. The vast majority of patients seek therapy because they are unable to channel their emotions into constructive forms of expression and activity. As a consequence, people get worried and resort to self-defense. As a result of these defenses, patients experience repercussions and symptoms. 8 Concerns about sexual dysfunction, such as reduced or lack of desire or premature ejaculation, may be obscured by fear and worry, as well as emotions of shame or embarrassment, inadequacy, and guilt. These hidden concerns might manifest as a number of symptoms in a range of circumstances, such as physical discomfort, despondency, or marital discontent. As a result, it leads to heated fights inside the family as well as divorce. 9 Sutherland 10 indicates that women's sexual troubles have an impact not just on their quality of life but also on their selfperceptions and interpersonal relationships. According to scholarly studies, sexual irregularities in women are harmful on a physiological, emotional, and social level. [11][12][13] A man who believes that his wife does not understand him is more likely to engage in self-defense and self-care activities. Defenses, in general, are mental procedures that exclude unpleasant emotions-ideas, sensations, or both-from conscious to consciousness. 14 Defenses might take the shape of ideas, feelings, or both. To make matters worse, our culture is among the few that do not participate in the practice of addressing such topics and difficulties. According to the random effect model (inverse variance technique), the overall prevalence of female sexual dysfunction in Iran was determined to be 43.9%, with a 95% confidence range spanning from 35 (11.5-31.8), and pain disorders in 40.1% (31.8-48.3) of people. 15 Depressive disorders and their treatment are a major concern due to their high prevalence and high burden in terms of disability, treatment costs, effects on families and carers, and loss of workplace productivity Effectiveness of Short-Term Dynamic Group Psychotherapy in Primary Care for Patients with Depressive Symptoms. Depression is a leading cause of disability worldwide and contributes significantly to the global disease burden. [16][17][18][19][20][21][22] When life is seen to be a tough process, psychotherapy treats emotional or psychological suffering as its major emphasis. It reveals how the mind is involved in the effort to face and endure pain, as well as how barriers or systems are built to prevent suffering from occurring. The bulk of these activities occur outside of conscious awareness and involve patterns of observation, thought, emotion, and action. However, because of our limited awareness, most of the time our subconscious attempts to reduce emotional suffering fail, despite being performed numerous times. 23,24 Psychiatric therapy both supports the person in their distress and works to change how they feel while undergoing treatment. It increases both the therapist's and the patient's understanding of these themes to increase the patient's ability to withstand emotional pain, deal with discontent, and become involved in their experiences. 15 Habib Davanloo, an Iranian psychotherapist, developed shortterm, intense psychoanalysis at McGill University. It is based on the Freudian psychoanalytic paradigm and employs a more focused kind of analysis. Raven's long-term analytic technique, which was inefficient, unstructured, and nonspecific, is replaced with a more practical, systematic, and transparent short-term strategy. "Freud discovered the subconscious, and Davanloo taught himself how to use it for treatment," Malan explains. "The subconscious was discovered by Freud." 25 A variety of studies have been conducted in this field. Parisuz et al., 26 for example, investigated the effects of vigorous short-term dynamic psychotherapy on marital conflict resolution and interpersonal processing in married women who were emotionally prepared to divorce. They discovered that the experimental group had greater interpersonal processing (F = 85.43, p = 0.01) and lower conflict levels (F = 43.93, p = 0.01) than the control group. As a result, intensive short-term dynamic psychotherapy (ISTDP) reduces the incidence of negative sentiments and the resulting marital conflicts, while also improving married couples' interpersonal processing skills.
A total of 115 individuals were treated for depressive symptoms and underwent 75 min of psychotherapy over a 9-month period (37-39 sessions) (n = 70) or standard treatment (n = 45). Bros et al. 27 studied the effectiveness of short-term group psychotherapy for patients with depressive symptoms in primary care. According to the findings of their study, the mean improvements after treatment were bigger in the psychotherapy group, and the difference in mean benefit between the two groups was statistically significant for the psychotherapy group. According to the data, this medication was effective in treating depressive symptoms.
Solbakken and Abbass 28 evaluated the personality disorder symptoms and changes that occurred after the treatment of refractory anxiety disorders and depression with short-term dynamic psychotherapy in 95 patients who had previously been unsuccessful with therapy. According to the findings, this therapy regimen was beneficial for individuals with severe and refractory mental problems. Overall, the data revealed that this therapy regimen had favorable results. Heidarinasab et al. 29 investigated the efficacy of this therapy in reducing symptom intensity and the frequency of defensive behaviors shown by depressed people.
Psychotherapies that are dynamically oriented are effective treatments for a variety of mental diseases, including depression.
When compared to control conditions, a recent meta-analysis of 23 studies, including short-term psychodynamic psychotherapy for depression, indicated a significant reduction in depressive symptoms. 30 Patients with moderate-to-severe depression in the community mental health system exhibited moderate-to-large effect sizes in favor of brief dynamic psychotherapy over traditional treatment in a randomized pilot study. 22,[31][32][33] However, empirical evidence on the effectiveness of psychodynamic psychotherapy in patients with depressive symptoms in primary care settings is limited. 34 According to the results, intensive dynamic psychotherapy for a shorter amount of time was beneficial in lowering depressive symptoms and inadequate and immature defensive styles and raising defensive styles after treatment. In light of the need for additional research on marital and family issues in a socially and culturally evolving society like Iran's, approaches that have been less well-tested in this area, as well as their efficacy on sensitive issues like sexual desire, marital satisfaction, and depression, should be considered. This is due to Iran's social and cultural evolution. As a result, the present study was designed to look into the effect of short-term psychotherapy on sexual desire and marital satisfaction in depressed women. The sample size was determined by the comparison formula for a quantitative feature in two groups as well as its parameters, which are referred to as a 95% confidence coefficient and a 90% test power.
Because two individuals are recommended as the minimum number of samples for sexual desire and six individuals are recommended as the minimum number of samples for marital satisfaction, the recommended minimum number of samples should be six individuals. However, the sample size was raised by 10% due to the likelihood of people falling while participating in the study. However, to increase the test's power and generate more reliable results, the sample size for both the intervention and control groups was established at 30 (60 in total). Cleophas et al. 35 Statistics Applied to Clinical Trials, Springer Netherlands.

| Beck Depression Inventory (BDI)
The questionnaire's 21 questions are classified into three categories: emotional symptoms, cognitive problems, and physical symptoms.
Each item is assigned a score ranging from 0 to 3. The highest possible score is 63, while the lowest possible score is 0.  Furthermore, the instrument's validity revealed that there is a significant difference between the mean of the overall scale scores and the scores for each of the domains (p = 0.001). According to Mohammadi et al., 39 the appropriate cut-off score on the entire scale for diagnosing sexual dysfunction was 28, and 83% of women with abnormalities were accurately identified, whereas 82% of women without abnormalities were not. Furthermore, 82% of women who had no anomalies received the proper diagnosis.

| Procedure
The following criteria were required for participation in the study: the participant had to be married and had been diagnosed with a sexual desire issue by a psychologist. Exclusion from the trial was based on the subject having concurrent treatment with other medications or psychological therapy.
The study population in this specific research attempt consisted of women who were diagnosed by a specialist as having sexual dysfunction and were sent to the Isfahan Marital Care Clinic due to a depressive disorder. Following sample selection based on availability, they were arbitrarily separated into two intervention and control groups (the random assignment was performed based on the case file number of the selected patient; in this instance, even numbers were assigned to the intervention group and individual numbers were assigned to the control group).

| Treatment
The In order for participants to gain a greater understanding, therapists seek to clarify unpleasant experiences, improve communication, and grasp unconscious dynamics. In this way, participants may have a better awareness of themselves, improve interpersonal connections, acquire T A B L E 1 Summary of the content of intensive short-term dynamic psychotherapy sessions.

First session
We discussed the rules for conducting therapeutic sessions and the initial interview with the implementation of the scan sequence, called experimental therapy, to evaluate the patient's initial problem.

Second session
Follow-up was performed if the experimental treatment responded appropriately. From this moment, that is, from the second session onwards, according to the type of (11) defense, appropriate and effective interventions have been implemented for each patient's defenses. Types of common tactical defenses and effective interventions related to each defense are summarized below. At the end of the last session, the follow-up program, especially the posttest time, was announced, the patients were thanked, and the end of the sessions was announced.
healthier symptoms, and build more flexible attitudes in everyday life 39 ( However, to increase the test's power and generate more reliable results, the sample size for both the intervention and control groups was established at 30 (60 in total) (Figure 1).

| Statistical analysis
To determine the normal distribution of data, the Kolmogorov-Smirnov test was applied. In addition to descriptive statistics, the univariate analysis of covariance (ANOVA) was used to assess the data that was gathered in light of the study objectives. All tests were analyzed through the SPSS statistics software V.24 at the significance level of p < 0.001.

| RESULTS
There were around 55% of individuals who were between the ages of 18 and 28, 30% between the ages of 29 and 39, and 15% between the ages of 40 and older. In terms of education, 42.54% only had a high school diploma or a lesser level of education, 28.64% had technical education after high school, and 28.82% had a college degree.
Both the experimental and control groups reported the mean and standard deviation of participants' ratings of marital satisfaction, sexual function, and depression. As seen in Table 2 Table 3 that shown data normally and the defaults have been met.
The results of MANOVA revealed that there was a significant difference between the short-term dynamic psychotherapy and control groups in terms of marital satisfaction, sexual function, and depression (p < 0.001), and the statistical power of 86% also showed that the sample size was sufficient for analyses (Table 4).
ANCOVA was conducted to find out the difference observed.
Considering the calculated effect size, 51% of the total variances of experimental and control groups was the result of the effectiveness of the independent variable. Moreover, the statistical power of the test was 0.80, which means that the test was able to reject the null hypothesis with a power of 51% (Table 5). The clinical evaluation reveals that boosting interpersonal interaction and improving clients' abilities in the treatment process The findings also revealed that short-term dynamic psychotherapy sessions increased sexual desire in women with depression as compared to the control group. When compared to the control group, this was the case. Short-term dynamic psychotherapy results from Fooladi et al., 51 Mohamadzadeh and Hoseini, 52 Mami and Heidary, 42 and Driessen et al. 30

| Limitations
This study, like other types of research, has certain flaws. Because the research sample was comprised of depressed women, it is crucial to take care when attempting to apply the findings of this study to women suffering from other conditions. Furthermore, the sample population of this study exclusively comprised female participants from the city of Isfahan. Furthermore, the researchers did not track the therapeutic results throughout the experiment. It has been proposed that future statistical population selection studies look at women suffering from depression in a range of settings. This is due to the cultural and social contrasts between these two locations.
The use of an available sample approach, the limiting of participants to females, a lack of appropriate time and crucial teamwork to follow up and analyze the durability of treatment effects, and the research being done entirely on women were all flaws in this study. In general, counsellors and psychotherapists consider that intense short-term dynamic psychotherapy is an appropriate intervention in the counselling center for improving sexual performance and marital satisfaction in women suffering from depression. This is because it is regarded as an effective remedy for improving sexual performance and marital satisfaction in depressed women.
Furthermore, the researchers did not track the therapeutic results throughout the experiment. In light of this, it is highly advised that larger samples be employed in future research to investigate some of the potential variables that may have an impact on the control group.
Furthermore, a variety of additional ways of gathering information centered in the community, such as interviews, might be utilized to test this group to widen the range of the information acquired. It is also suggested that research into additional intervention approaches and features of this business be done and that the findings be compared and assessed together. In general, counsellors and psychotherapists should prescribe rigorous short-term dynamic psychotherapy as a suitable strategy to improve sexual function, marital satisfaction, and depression in women suffering from depression.

| CONCLUSION
The findings of this study provide preliminary evidence that ISTDP is more successful than minimal contact in treating depression in people. It adds to the studies that have previously proven the treatment to be clinically helpful as well as cost-effective, with benefits that last for a long time. The limitations of this study must be addressed in future ISTDP research, including this demography as well as the introduction of formal cost-benefit analyses. Furthermore, it must explore the specific impacts of patient variables, therapist factors, and therapeutic factors (e.g., emotional experiences writing-original draft; writing-review and editing.

ACKNOWLEDGMENTS
All participants in this study are appreciated.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

TRANSPARENCY STATEMENT
The lead author Arash Ziapour affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
The data supporting the findings in this study will be made available through the corresponding author upon reasonable request. The corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

ETHICS STATEMENT
The study was approved by the Research Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1399.1105).
Written informed consent was obtained from all group members.
Consent to submit has been received explicitly from all coauthors, as well as from the responsible authorities-tacitly or explicitly -at the institute/organization where the work has been carried out before the work is submitted. The purpose of this research was completely explained to the participants through the cover page of the questionnaire, and they were assured that their information would be kept confidential by the researcher. Informed consent from the participants was acquired as they agreed to participate in the study by reviewing the questionnaire's cover page and clicking on the provided link. Furthermore, for participants younger than 18 years of age, the participant was asked for the consent of the parent or guardian.